Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Coast Post Acute during CMS and state inspections, most recent first.
Failure to follow up on surgeon and oncology referrals for a resident with left breast cancer and metastatic axillary lymph node disease. The DON could not locate documentation showing the referrals were scheduled, completed, or refused, and there was no record of family notification. An oncology consult later noted no records of complete cancer staging and that the oncologist did not know why the resident had not been referred for further evaluation or treatment.
A resident with schizoaffective disorder, bipolar disorder, vascular dementia, severe cognitive impairment, dependence for mobility, and a documented history of multiple falls was assessed as high fall risk with care‑planned interventions including close supervision, monitoring whereabouts, and providing activities to keep the resident occupied. On the day of the incident, the resident sat in a hallway chair for about two hours, repeatedly attempted to stand, and was supervised by a single CNA overseeing approximately 15 residents while other CNAs assisted residents in rooms. Staff reported they typically used snacks and redirection when the resident tried to stand, but at the time of the fall the CNA turned away to assist another resident, no activities were provided to keep the resident occupied, and the resident was later found on the floor in a nearby room with a head laceration requiring hospitalization and staples, despite prior assessments and a rehab screen recommending 24/7 supervision for impulsive, high‑risk behavior.
The facility failed to submit a required 5‑day investigation report to the State Survey Agency after an alleged altercation in which a CNA found one resident with dementia and major depressive disorder being held by the chest and hit in the face by his roommate, who had a history of stroke, dementia, anxiety disorder, and major depressive disorder. Health Status Notes documented the incident for both residents, but later document review showed no 5‑day investigation report on file. The ADM reported that the investigation report had been completed but was never emailed or faxed to the Department, contrary to facility policy requiring that findings of all abuse investigations be documented and reported within five business days.
A resident with ESRD, DM, and dependence on dialysis had a physician order for a 1000 cc/day fluid restriction, with specific fluid allotments divided between Dietary and Nursing. Intake records showed repeated days where the resident’s fluid intake exceeded the ordered amount, sometimes substantially, without documentation that the physician was notified. The resident reported no difficulty obtaining drinks from staff, and an LVN stated the resident typically received additional hot chocolate beyond the ordered restriction. The DSD confirmed the intake findings, while facility policies required adherence to fluid restriction parameters, prompt physician notification of changes in condition or status, and care of ESRD residents according to recognized standards of care.
A resident with significant medical needs and a history of homelessness was discharged without a finalized discharge date or documented destination. The discharge occurred unexpectedly, without proper communication or documentation by the IDT, and the required discharge planning process was not followed, resulting in incomplete discharge planning.
A resident with diabetes and other complex conditions did not receive blood glucose monitoring as frequently as required by facility policy, and staff failed to notify the physician of significant increases in blood sugar. Additionally, staff did not notify the physician when the resident's oxygen saturation repeatedly fell below the ordered threshold. These failures were confirmed by facility staff and led to the resident's transfer to the hospital after a critical decline.
The facility failed to comply with food safety standards, as undated and expired food items were found in storage, and staff did not adhere to hygiene practices by not washing hands upon entering the kitchen. Additionally, juice was served at a temperature above the acceptable range. These deficiencies could lead to foodborne illnesses among residents.
The facility failed to provide meals according to the dietary preferences and needs of four residents, including serving incorrect milk types and ignoring allergies and dislikes. The dietary director confirmed these discrepancies, which contradict the facility's policy to adhere to residents' food preferences.
The facility failed to implement proper infection control practices, including hand hygiene during wound care, capping enteral feeding tubes, and proper handling of oxygen tubing. Additionally, CNAs were observed leaving rooms with gloves on, contrary to policy. These actions could lead to infection spread.
A resident with multiple health issues, including severe memory problems and impaired lower extremity function, was unable to reach their call light button, which was found tucked between the bed frame and mattress. Staff interviews confirmed that the call light should have been accessible, as per facility policy.
The facility failed to administer medications correctly for two residents. A resident with anemia received ferrous sulfate and calcium-vitamin D concurrently, leading to a significant drug interaction. Another resident with COPD did not receive proper instructions during Fluticasone inhaler administration, as the LVN failed to instruct the resident to inhale deeply and hold their breath, contrary to facility policy.
A resident with dysphagia was served chopped meats instead of the prescribed mechanical soft diet with ground meats. The dietary director confirmed the error during a tray line observation, acknowledging the resident should have received the correct diet texture.
A facility failed to develop a comprehensive care plan for a resident prescribed antibiotics for burning urination and did not address changes in the resident's condition, including bradycardia and increased confusion. The lack of a care plan was confirmed by the DSD, despite facility policy requiring updates for significant condition changes.
A facility failed to report an allegation of abuse against an LVN to the proper authorities, as required by their policy. The DON was informed of the allegation but did not notify the police, citing a misunderstanding of the reporting requirements. The resident involved had a history of cerebral vascular disease, Alzheimer's, major depressive disorder, anxiety disorder, and falls.
Failure to Follow Up on Oncology and Surgeon Referrals
Penalty
Summary
The facility failed to ensure follow-up of surgeon and oncology referrals for Resident 1, who had diagnoses including malignant neoplasm of the left breast, metastatic disease to the left axillary lymph node, and dementia. A pathology report dated 12/13/24 showed invasive ductal carcinoma of the left breast and metastatic adenocarcinoma involving the left axillary lymph node. On 12/17/24, the physician reviewed the pathology report and ordered referrals to a general surgeon and an oncologist, and on 1/31/25 the physician again ordered a referral to oncology for left breast metastatic cancer. During interview and record review, the DON stated the facility could not locate the scheduler's appointment calendar and could not find documentation showing the 12/17/24 surgeon and oncology referrals were scheduled or completed. The DON also stated there was no documentation that Resident 1 refused the referrals and that refusals and family notifications would normally be documented in the Health Status Note. On 6/4/26, the DON provided the 1/31/25 oncology referral order and confirmed there was no documentation showing the referral was scheduled, completed, or refused. The oncology consultation report dated 10/13/25 noted the oncologist reviewed the pathology results, stated there were no records of complete staging for the breast cancer, and indicated no further workup or referrals at that time.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall prevention interventions for a high‑risk resident, resulting in a fall with head trauma. The resident had diagnoses including schizoaffective disorder, bipolar disorder, vascular dementia, muscle weakness, and a history of repeated falls. The Minimum Data Set dated 1/12/26 documented severely impaired decision‑making, impaired short‑ and long‑term memory, and dependence for sit‑to‑stand, transfers, toileting, and mobility. Fall risk assessments and care plans identified the resident as high risk for falls, with risk factors such as impaired vision, unsteady gait, impaired mobility, cognitive impairment, wandering, psychoactive medication use, and gait/balance problems. Interventions in the comprehensive fall risk care plan included monitoring whereabouts, assisting with toileting, ensuring a safe environment, and providing activities to keep the resident occupied to reduce unassisted standing. On the date of the incident, documentation and interviews indicated the resident had been sitting in a hallway chair for approximately two hours and had been attempting to stand and walk prior to the fall. The SBAR and progress notes stated that at approximately 2100, staff heard a loud sound and found the resident on the floor in a nearby room by the doorway with a head laceration and significant bleeding. The SBAR indicated the resident had been sitting in the hallway for about two hours and that staff were assisting another resident at the time of the incident, with the CNA approximately five feet away when the resident was found on the floor. The hospital discharge summary confirmed the resident was hospitalized following the fall and sustained a head laceration, and noted the need for close supervision as evidenced by the recent fall while unsupervised. A subsequent skin assessment documented a 5 cm x 2 cm laceration to the back of the head closed with 13 staples. The resident’s clinical record showed a pattern of prior falls, both witnessed and unwitnessed, some with injuries such as brow swelling, knee discoloration, wrist swelling, and forearm discoloration. A rehab post‑fall screen dated 8/12/25 identified the resident as at high risk for falls due to cognitive deficits and impulsive movement patterns and recommended continued 24/7 supervision. Interviews with staff, including the CNA, LVN, and DON, confirmed that the resident was known to be very impulsive, a high fall risk, and had a history of attempting to stand and ambulate without assistance. Staff reported that when the resident attempted to stand, they would typically provide snacks and redirect the resident to sit, and that activities to keep the resident occupied were an intervention to prevent falls; however, at the time of the fall, the CNA was supervising approximately 15 residents alone in the hallway, turned away to assist another resident, and no activities were provided to keep the resident occupied during repeated attempts to stand. The facility’s falls policy stated that staff would try various relevant interventions based on assessment until falling reduced or stopped or a reason for continuation was identified, but the documented circumstances show that the planned interventions, including close supervision and provision of activities, were not effectively implemented at the time of the incident.
Failure to Submit 5‑Day Investigation Report After Resident‑to‑Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to submit the required 5‑day investigation report to the State Survey Agency (SSA) following an alleged resident‑to‑resident altercation. Resident 2, who had vascular dementia and major depressive disorder, was documented in a Health Status Note as having yelled out from his room on 2/2/26. A CNA responded and observed Resident 3 standing next to Resident 2’s bed, holding Resident 2’s chest with one hand and hitting Resident 2 in the face; the CNA intervened and separated the residents. Resident 3’s clinical record, which included diagnoses of cerebral infarction, dementia, anxiety disorder, and major depressive disorder, contained a corresponding Health Status Note describing the same observed behavior. On 4/16/26, review of facility documents showed there was no 5‑day investigation report on file that had been submitted to the SSA within the required timeframe for this alleged altercation involving Residents 2 and 3. During an interview, the Administrator stated that the 5‑day investigation report had been completed but was not emailed or faxed to the Department and was unsure why it was not sent, noting that the facility usually emails investigation reports within five days. The facility’s undated policy titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating” states that all reports of resident abuse are to be reported to local, state, and federal agencies as required, with findings of all investigations documented and reported, and that within five business days of the incident the administrator will provide a follow‑up investigation report. This policy requirement was not met for the incident involving Residents 2 and 3.
Failure to Follow Fluid Restriction and Notify Physician for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s fluid restriction order and to notify the physician of excessive fluid intake for a resident receiving dialysis. The resident had diagnoses including type 2 DM, ESRD, and dependence on dialysis, and had a physician’s order dated 12/19/25 for a 1000 cc/day fluid restriction, with 600 cc to be provided by Dietary (240 cc at breakfast, 120 cc at lunch, 240 cc at dinner) and 400 cc by Nursing (100 cc on night shift, 180 cc on day shift, 120 cc on evening shift). Review of the resident’s daily intake records showed multiple days on which the resident’s fluid intake exceeded the ordered 1000 cc, including intakes such as 1260 cc, 1460 cc, 1740 cc, and other amounts above the prescribed limit on various dates. There was no documentation in the medical record that the physician had been notified about these episodes of excessive fluid intake. During observation and interview, the resident stated he was on a fluid restriction, was not receiving food or drink from outside, and reported having no difficulty obtaining drinks from facility staff. An LVN acknowledged that the resident was on fluid restriction but usually consumed more than ordered on the day shift due to an additional 240 cc of hot chocolate in the morning, and further acknowledged that the fluid restriction order should be followed and the physician should be notified of excessive intake. The Director of Staff Development confirmed the record findings and stated staff should follow the fluid restriction order and notify the physician of excessive fluid intake. Review of facility policies on encouraging and restricting fluids, change in a resident’s condition or status, and care of residents with ESRD showed expectations that residents receive the amount of fluids necessary to maintain optimum health, that physicians be promptly notified of changes in condition or status, and that ESRD residents be cared for according to recognized standards of care.
Incomplete Discharge Planning and Documentation
Penalty
Summary
The facility failed to complete discharge planning for a resident with a history of hemiplegia, hemiparesis following cerebral infarction, and orthostatic hypotension, who was homeless prior to admission. The resident's discharge care plan included goals for appropriate placement and safe transition to the community, with interventions to assess preferences and coordinate necessary services. However, documentation revealed that there was no finalized discharge date or documented place of discharge. Social service notes indicated ongoing discussions about discharge, but no specific date was set, and the discharge ultimately occurred on a day not planned by the interdisciplinary team (IDT). The Social Service Director (SSD) and Director of Nursing (DON) both confirmed that the discharge was unplanned and not communicated or documented as required. On the day of discharge, the resident left the facility with his son, and the SSD was not present to document the destination or ensure the discharge plan was finalized. The facility's policy required a finalized discharge plan, including the resident's destination, to be reviewed with the resident and family at least 24 hours prior to discharge. This process was not followed, and the discharge summary lacked essential information about the resident's post-discharge arrangements. The lack of documentation and communication resulted in incomplete discharge planning for the resident.
Failure to Follow Diabetes Management Policy and Physician Orders for Monitoring
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with multiple diagnoses, including type 2 diabetes mellitus, chronic kidney disease, cervical vertebra fracture, and traumatic subdural hemorrhage. The facility did not follow its own diabetes management policy, which required blood glucose monitoring twice daily for residents on insulin. Instead, the resident's blood sugar was only checked once daily at bedtime, despite significant fluctuations and increases in blood glucose levels. Additionally, there was no documentation that the physician was notified when the resident's blood sugar rose sharply from 89 mg/dL to 380 mg/dL. The facility also failed to follow physician orders regarding monitoring and notification for low oxygen saturation (O2 sat). The resident's O2 sat was repeatedly below the ordered threshold of 94% on multiple shifts, but there was no evidence that the physician was notified as required. Ultimately, the resident experienced a critical decline, with an O2 sat of 78% and a blood glucose of 588 mg/dL, resulting in transfer to the hospital. Interviews with facility staff confirmed these failures to follow both facility policy and physician orders.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by the presence of undated and expired food items, as well as rotten vegetables in the kitchen's storage areas. During an inspection, numerous food items were found without open or use-by dates, including large quantities of apple base, iced tea, thicken water, sugar cookie dough, and various dairy products. Additionally, several fruits and vegetables, such as tomatoes, cantaloupes, and lettuce, were either rotten or lacked proper dating. The dietary director acknowledged that these items should have been labeled with open and use-by dates, and expired items should have been discarded according to the facility's policy. The facility also failed to maintain proper hygiene practices in the kitchen. Observations revealed that both a dietary aid and the maintenance director entered the kitchen without washing their hands, which is a violation of the facility's hygiene policy. The dietary aid admitted to not washing her hands upon entering, and the maintenance director also acknowledged his failure to do so. The director of staff development and infection preventionist confirmed that staff are required to wash their hands when crossing the designated red line in the kitchen. Furthermore, the facility did not ensure that beverages were served at the correct temperature. During a test tray observation, the temperature of the juice was recorded at 66.6 degrees Fahrenheit, which exceeded the acceptable delivery temperature range of 40 to 55 degrees Fahrenheit. The dietary director confirmed the temperature was too high and indicated a need to verify the acceptable delivery temperature for the juice. These deficiencies in food storage, hygiene practices, and temperature control could potentially lead to foodborne illnesses among the 144 residents receiving food at the facility.
Failure to Adhere to Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals according to the preferences and dietary needs of four residents, leading to potential dissatisfaction and compromised nutritional status. During a tray line observation, it was noted that a resident who preferred low-fat milk was served whole milk, and another resident who preferred yogurt did not receive it. The dietary director confirmed these discrepancies, acknowledging that meals should have been served according to the residents' preferences. Additionally, a resident with an allergy to melon was served a fruit dish containing cantaloupe, despite her tray card indicating her allergies and dislikes. Another resident reported during a resident council meeting that her preference to avoid honeydew melon was not respected, as it continued to appear on her tray. The facility's policy states that residents' food preferences should be adhered to within reason, yet these instances demonstrate a failure to comply with this policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. During a wound dressing change for a resident with osteomyelitis and a stage 4 pressure ulcer, the treatment nurse did not perform hand hygiene between glove changes, which is against the facility's policy. The Director of Staff Development/Infection Preventionist confirmed that hand hygiene should be performed between glove changes. In another instance, the tips of enteral feeding tubes for two residents were left uncapped and exposed, contrary to the facility's policy requiring them to be capped to prevent contamination. The Licensed Vocational Nurse and the Director of Nursing acknowledged that the feeding tubes should have been capped when not in use. Additionally, oxygen tubing for three residents was found lying on the floor and undated, which was not in compliance with the facility's infection control policy. The staff confirmed that the tubing should have been stored in a bag and dated. Furthermore, two certified nursing assistants were observed leaving residents' rooms with gloves on and removing them in the hallway, which is against the facility's policy that requires gloves to be removed in the resident's room. The Director of Staff Development/Infection Preventionist stated that gloves should be removed in the resident's room before exiting. These failures in infection control practices had the potential to result in the transmission and spread of infection within the facility.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's care needs were accommodated when the resident's call light button was not within reach. This deficiency was identified for one of four sampled residents, who was admitted with diagnoses including heart failure, gout, osteomyelitis, and muscle weakness. The resident also had impaired functional use of both sides of his lower extremities and severe memory problems, as indicated by a low score on the Brief Interview for Mental Status (BIMS). During an observation, the resident was unable to locate or reach the call light button, which was found tucked between the bed frame and mattress. Interviews with facility staff confirmed the deficiency. A Certified Nursing Assistant (CNA) acknowledged that the call light button should have been within reach for the resident. The Director of Nursing (DON) also stated that the call light button should always be accessible to residents. The facility's policy and procedure on answering call lights indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair. This oversight had the potential to delay care and treatments for the resident.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards for two residents. Resident 64, who was diagnosed with anemia, received ferrous sulfate and calcium-vitamin D at the same time every other day since September 13, 2024. This concurrent administration led to a significant drug-drug interaction, as calcium can decrease the absorption of iron by an average of 60%. This interaction was confirmed by the Director of Nursing (DON) during a review of the resident's clinical record. Additionally, Resident 98, who has Chronic Obstructive Pulmonary Disease (COPD), did not receive proper instructions during the administration of Fluticasone inhaler medication. The Licensed Vocational Nurse (LVN) A failed to instruct the resident to inhale deeply and hold their breath after administering the medication, which is contrary to the facility's policy and procedure for administering medications through a metered-dose inhaler. The DON confirmed that the correct procedure was not followed, which could have impacted the effectiveness of the medication for the resident.
Inappropriate Diet Texture Served to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the appropriate diet texture for a resident diagnosed with dysphagia, a condition characterized by difficulty swallowing. The resident was admitted with a requirement for a mechanical soft diet with ground meats, as indicated on her lunch ticket. However, during a tray line observation, it was noted that the resident was served chopped meats instead of the prescribed ground meats. The dietary director confirmed the discrepancy, acknowledging that the resident should have received a mechanical soft texture meal with ground meats.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was prescribed antibiotic therapy to treat burning urination. Despite the prescription of Cipro, an antibiotic, on November 3, 2024, the facility staff did not create a care plan to address the antibiotic treatment or monitor the resident's response to the therapy. This oversight was confirmed during an interview and record review with the Director of Staff Development (DSD), who acknowledged that a care plan should have been in place. Additionally, the facility did not develop a care plan to address the resident's change in condition, which included bradycardia, low oxygen saturation, and increased confusion. These changes were documented in health status notes on November 11 and November 14, 2024, with the resident eventually being transferred to the hospital for further evaluation. The DSD confirmed that no care plan was developed to address these changes, despite the facility's policy requiring updates to care plans when there is a significant change in a resident's condition.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting of suspected abuse for one resident. The deficiency involved an incident where an allegation of abuse against a licensed vocational nurse (LVN A) was not reported to the proper authorities. The Director of Nursing (DON) was informed of the allegation but did not report it to the police, stating that they would have done so if notified by someone other than the California Department of Public Health (CDPH). The facility's policy, dated 2001, requires immediate reporting of suspected abuse to the administrator and other officials as per state law. The resident involved had a medical history that included cerebral vascular disease, Alzheimer's disease, major depressive disorder, anxiety disorder, and a history of falling.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salinas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salinas Valley Post Acute | 0 mi | ★★★★★ | 29 | 0 |
| Katherine Healthcare | 0.6 mi | ★★★★★ | 23 | 0 |
| Coastal Post Acute | 2.6 mi | ★★★★★ | 0 | 0 |
| Windsor The Ridge Rehabilitation Center | 2.6 mi | ★★★★★ | 13 | 0 |
| Carmel Hills Care Center | 12.6 mi | ★★★★★ | 31 | 0 |
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